What are the options for electronic patient records in the NHS after NPfIT?

Many hospitals lack comprehensive electronic patient record (EPR) systems. What are the options now, in the wake of the NPfIT disaster?

It is a common assumption that the NHS can’t do IT. This is untrue: most GP surgeries are computerised, the health services of the UK’s constituent nations have decent technology infrastructure including secure networks and email, and many hospitals departments have good specialist IT.

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What is true is that many hospitals lack comprehensive electronic patient record (EPR) systems. In England, this can be blamed on the disastrous £12bn National Programme for IT (NPfIT). In The blunders of our governments, a survey of government disasters including numerous IT projects, authors Anthony King and Ivor Crewe describe NPfIT as “the veritable RMS Titanic of IT disasters” and “doomed from the beginning”.

NPfIT did a reasonable job in some areas, including infrastructure and specialist imaging systems for trusts. But it failed on EPR systems - by the spring of 2007, it was due to have delivered 155 systems, and had managed 16.

What's more, those with new systems were the unlucky ones, wrote King and Crewe: “Where the systems were installed, they frequently crashed totally, malfunctioned in other ways and/or failed to connect with other systems they were supposed to connect with.” They cite a Computer Weekly article from September 2006, of 110 major incidents caused over the previous four months.

Part of Cambridge’s £200m eHospital project, which also includes a massive hardware upgrade, the introduction of Epic took 18 months. More than 100 of the trust’s staff took exams to qualify as application analysts, allowing them to adapt Epic’s software to Cambridge’s processes, work which involved around 1,000 staff in total – before general staff training.

The trust expected to spend £40m of the eHospital budget with Epic, with a further £20m for its own costs. The system went live on the weekend the trust planned to do so, but has since experienced teething problems with areas including poor quality discharge summaries (sent by the trust to GPs on patients’ treatment) and clinic letters. Such problems are hard to avoid with such a large project, however much preparation is carried out.

Open to open source

A new commercial EPR will cost millions, perhaps tens of millions, of pounds. Open source software can provide a cheaper alternative in terms of licence fees, and is favoured by the Department of Health – such projects were encouraged in its most recent round of technology funding for trusts. However, projects are likely to require a capable IT department and a significant implementation budget.

Some leading NHS trusts have developed their own open source software, including Moorfields Eye Hospital. Its OpenEyes EPR has been designed for ophthalmology, and has been adopted by NHS Wales for use across its health boards as well as by a few other English trusts. But while OpenEyes focuses on a specialist area of healthcare, its elements have wider uses, particularly if a trust can undertake its own development - a 2013 NHS Hack Day saw the package adapted for heart surgery, under the name OpenHeart.

As well as adapting open source software written by the NHS, there is the option of paying a company to do this. Taunton and Somerset NHS foundation trust has taken this route, last year awarding UK software firm IMS Maxims a contract to implement its own open source EPR software at the trust.

Portals of discovery

Many NHS organisations have a collection of software applications – some trusts have hundreds – and prefer to link them up than replace them. The answer is often a portal, which joins up existing systems and allows staff to see all parts of a patient’s record, even as the data remains fragmented.

Largely because the intended end-users of the scheme had been so little consulted, the IT suppliers often had no clear idea of what they were supposed to be supplying

From The blunders of our governments, by Anthony King and Ivor Crewe

Portals tend to be a relatively cheap option both in terms of spending and training, and can also help to establish joint-working with other organisations or in knitting together units after a merger. January saw Sheffield Teaching Hospitals NHS Trust, one of the largest trusts which runs five hospitals, install a portal with HP, Orion Health and Imprivata.

There are disadvantages in using a portal - setting up integration often takes effort, and maintaining a large number of ageing applications may well cost more in time and trouble in the long run than making a clean break. But if a single new system is a step too far, a portal can be an attractive alternative.

Working on your image

Another option for trusts that prefer to maintain a range of systems is to introduce or improve a few key ones. Imaging, with its requirement for high-capacity IT to hold the likes of X-rays and CT scans, provides obvious candidates. Most acute trusts in England received a radiology information system (RIS) and picture archiving and communications system (PACS) through NPfIT. But the recent expiry of these contracts has led to some including Gateshead NHS Foundation Trust to adopt a vendor-neutral archive, or VNA, to give them greater choice over suppliers in future.

Another imaging-related option is to scan paper records, of which many NHS trusts have tens of millions of pages. Managing these records is expensive in terms of staff to retrieve, deliver and refile them, and in office space. An electronic medical records (EMR) project to scan notes, make them available to staff through computers and move the paper off-site can often repay its costs in two or three years.

Basildon and Thurrock University Hospitals NHS Foundation Trust recently completed the scanning of 450,000 old records, through a four-year £7m deal with Kodak Alaris – which will save an estimated £2.6m a year in reduced costs and improved efficiencies. For the time being, the trust will continue to generate new records which will then be scanned, but plans to move to digital records in time. Some trusts introducing a comprehensive EPR chose to use EMR scanning for old notes, rather than fully digitise everything.

Talk to the staff

Regardless of the route chosen to a capable EPR, it is essential that users are involved. This is partly because healthcare procedures are often complex, carried out at high speed with high safety requirements, and partly because highly-paid medical professionals expect equipment to work – and if it doesn’t, they will not use it.

The authors of The blunders of our governments say that a lack of engagement with staff was a key problem with the National Programme for IT: “No-one ever thought to ask medical administrators and practitioners whether it was a high-priority project from their own point of view,” how it would work with existing systems or processes or whether they even wanted to use it. “Largely because the intended end-users of the scheme had been so little consulted, the various IT suppliers often had no clear idea of what they were supposed to be supplying – and in some cases merely sold the NHS whatever they happened to have on hand,” they added.

A common way to involve medical staff is to appoint a chief clinical information officer, such as Cambridge University Hospital’s Afzal Chaudhry, who as well as being one of the leaders of the eHospital project is also a consultant nephrologist (providing kidney care) and transplant surgeon. NHS England’s director of informatics, Professor Jonathan Kay, has called for every NHS provider and clinical commissioning group in England to appoint a CCIO. But while appointing one is a useful step, it needs to be accompanied by the involvement of staff across the organisation.

Learn from the past

Although any substantial EPR project takes several years, it is getting a bit late for trusts to blame the National Programme for IT for what they don’t have. Ironically, King and Crewe point out that the government originally intended to let trusts choose their own systems, but that choice was “nationalised” by the then-head of NHS Connecting for Health, Richard Granger.

The authors of The blunders of our governments also note that NPfIT was apparently never subjected to “a serious – or even a back-of-the-envelope – cost-benefit analysis”. Financial pressures mean that few trusts would dodge this now, and those applying for Department of Health technology funding have to include such analysis.

There are plenty of other ways in which major projects can go astray, such as weak management or oversight, too much ambition and rushed procurement – all of which applied to NPfIT. NHS trusts can draw benefits from the National Programme, through studying it as a case study of what not to do. What they can’t do now is use it as an excuse.

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We could start by acknowledging that we have a potential disaster on our hands. What are our options...? Examine the problem, rethink the solution and replace it with something that works..

Patients (and their doctors) need ready access to an ongoing history of medical records. Neither health care nor the drugs that care for our health is very simple anymore. That complexity demands access to EPR that we can trust. Trust to be available, trust to be accurate, trust to be safe.

Instead, we've devised a vault with a paper door, then told the most vulnerable to rely on it. Is that really the best we can do?

Our firewalls and encryption must have once made someone in the front office feel safe. Over time, more than a few bad lumps should have made those folks feel a lot less secure.

All they do is replace the paper door with a thicker piece of paper. "There, see, it's fixed, all better, let's move on...."

Mostly, it's hardly worth the bother.... It's been proven far too often, then yet again, that dedicated hackers can bludgeon their way past all our security. And the NSA can just unlock the back door to access whatever they want.

All our walls and locks are there merely to keep out the most casual eavesdropper. Beyond that, our whack-a-mole approach to security is woefully inadequate.